[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR456.123]



[Page 346]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 456_UTILIZATION CONTROL--Table of Contents

 

                Subpart C_Utilization Control: Hospitals

 

Sec.  456.123  Admission review process.



    The UR plan must provide that--

    (a) Admission review is conducted by--

    (1) The UR committee;

    (2) A subgroup of the UR committee; or

    (3) A designee of the UR committee;

    (b) The committee, subgroup, or designee evaluates the admission 

against the criteria developed under Sec.  456.122 and applies close 

professional scrutiny to cases selected under Sec.  456.129(b);

    (c) If the committee, subgroup, or designee finds that the admission 

is needed, the committee assigns an initial continued stay review date 

in accordance with Sec.  456.128;

    (d) If the committee, subgroup, or designee finds that the admission 

does not meet the criteria, the committee or a subgroup that includes at 

least one physician reviews the case to decide the need for admission;

    (e) If the committee or subgroup making the review under paragraph 

(d) of this section finds that the admission is not needed, it notifies 

the recipient's attending physician and gives him an opportunity to 

present his views before it makes a final decision on the need for the 

continued stay;

    (f) If the attending physician does not present additional 

information or clarification of the need for the admission, the decision 

of the committee or subgroup is final; and

    (g) If the attending physician presents additional information or 

clarification, at least two physician members of the committee review 

the need for the admission. If they find that the admission is not 

needed, their decision if final.